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1 medical questionnaire Date: Please answer these questions as completely as you can. We realize that this form is long, but the information in this form will be extremely valuable to us in providing you the best possible care. Patient s Name: Last First Middle Social Security No.: - - Driver s License No.: Date of Birth: Patient s Sex: M F Race: Patient s Address: Home Phone No.: Patient s Occupation: Emergency Contact: Work Phone No.: Employer: Phone No.: Relationship to Patient: IF OTHER THAN THE PATIENT, WHO IS RESPONSIBLE FOR PAYMENT OF SERVICES? Name: Address: Home Phone No.: Employer: Last First Middle Street City State Zip Code Relationship to Patient: Work Phone No.: WHO SENT YOU TO US OR FROM WHAT SOURCE DID YOU GET OUR NAME? (circle you choice) Physician Family / Friend Baylor Referral Service Yellow Pages Other IF PHYSICIAN REFERRAL, PLEASE PROVIDE ADDITIONAL INFORMATION: Physician: Address: Phone No.: Street City State Zip Code Department of Ophthalmology 7200B Cambridge Houston, Texas telephone: fax:

2 eye history List all eye diseases / conditions that your have, and indicate how long you have had them. eye condition of diagnosis eye condition of diagnosis eye surgery Have you had surgery on your eyes? No Yes If yes, please complete the following: eye condition Month/Year eye condition Month/Year EYE MEDICATIONS: What prescription and over-the-counter eye medicines are you using? Please indicate which eye, the number of times per day, and the duration that you have been using each drop, ointment, or oral medication. Eye Medication (circle choice) No. times per day For how long Do you wear glasses? No Yes If yes, for how long? Date last changed: Do you wear contact lenses? No Yes If yes, what type and for how long? Did you even have patches placed on your eyes when you were a child or have you been told that you had crossed eyes or a lazy eye? No Yes If yes, describe:

3 general medical history List your current and past illnesses (such as diabetes, hypertension, etc.) in chronological order, if possible. (Do not include eye conditions that you have previously listed.) Please list all previous surgical procedures (not involving your eyes) and their dates: Surgical Procedure MEDICATIONS: Please list all medications that your are currently taking and their dosage (if known): Medication Dose No. times per day For how long Are you taking aspirin or any other over-the-counter medicines? No Yes If yes, list: Do you have any known drug allergies? No Yes If yes, list:

4 HAVE YOU RECENTLY HAD ANY OF THE FOLLOWING SYMPTOMS OR PROBLEMS? General Fever Unexplained weight loss Night sweats Ear, nose, or throat Ringing in ears Hearing loss Pain Nervous System Headache Stroke Seizure / epilepsy Weakness, numbness, tingling Heart or circulatory problems Heart attack or heart failure Irregular heart rhythm Chest pain Pacemaker Hypertension Endocrine Thyroid disease Diabetes Hormonal disease Allergy / immunology Environmental allergies Iodine allergy Contrast material (dye) allergy Cat scratch or cat bite Skin / breast Masses / tumors Rash Discharge from breast No Yes No Yes Lungs / breathing Breathing difficulty Asthma Lung disease Digestive system Diarrhea Ulcer disease Hepatitis Genitourinary Kidney disease Urinary tract infection Urinary bleeding Altered menses Blood Anemia (low blood count) Blood tumors / disease Swollen glands Bleeding disorder Musculoskeletal Joint pain / arthritis Fractured bones Pain with chewing Scalp pain or tenderness Psychiatric Depression Mood swings Anxiety Admission to hospital psychiatric illness Other: COMMENTS:

5 PERSONAL HISTORY Are you: (circle one) Married Single Divorced Spouse deceased Do you or did you ever use alcohol? No Yes If yes, how much? Do you or did you ever smoke? No Yes If yes, when did you start? How much do you smoke each day? If you quit, at what age? Do you use street drugs? No Yes If yes, type? How frequently? Are you on a special diet? No Yes If yes, please describe: Who gives your medication(s) Myself Other: FAMILY HISTORY Does anyone in your family have any eye diseases? No Yes If so, what is their relationship to you and what type of eye disease do they have? THANK YOU FOR YOUR HELP! M.D. Initials:

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